The following notes should be considered just that – notes. Although it might at times read like a transcript, it is no such a thing. Beyond not being trained nor fast enough to transcribe, the acoustics were not such that I could hear every remark or word. As does any human, I tend to hear what I expect to hear or want to hear.
Worse, my appellations are mere conjectures as to identities and the spelling is my own creation. I apologize up front, I can only say that if I misidentified someone then I misidentified them consistently. I also followed no protocols – Micronesian or American. I tended to use the shortest name possible.
On the first day I was not near an outlet and had to conserve battery power. I did not take any notes other than those I deemed most critical.
This means that all of the discussion of primary and secondary health care is essentially omitted below. Half of the discussion of goal three involving the prioritization of the promotion of good health is likewise missing. My apologies.
At many points this document presumes that one has the health strategic planning matrix at hand. This is available on the summit web site at http://www.summit.fm
Occasionally where I am sure I have not heard, misheard, or lost a sentence necessary to clarification, I have inserted text. Inserted text is in [square] brackets. Sometimes meaning is embedded in timing, or a nod, or an interjection from the gallery. I often missed these.
Finally I would note that the presence of material below is not in any way a reflection of the sector's final opinion. There were certainly discussions that led to an agreement to drop the idea under discussion and to not carry it on to the plenary. The ideas may have been good ideas, but the group may have decided for a variety of reasons to set the idea aside. Often the problem was that the idea concerned decisions that belonged to other sectors.
This is in no way meant to supplant the work done by the raconteur, that work should be considered the official voice of the sector.
Tuesday Afternoon 30 March 2004
Jeff does introductions. Three meetings led to matrix. Everybody counts.
We are starting with the mission. 200403301359.
Is the mission a minimum standard or something more?
We are now going through the five standards. Read to us.
Discussion of community involvement and having outputs involving the community in regards primary health care.
Pohnpei: We agree with the percentages in the matrix, but we want to balance primary and secondary. If to much emphasize PHC then we might jeopardize SHC.
Valerio: Decrease in SHC goes to PHC? That is, the percentages are not equal. This is in reference 1.i and 1.ii where 50% increase in PHC utilization is hoped to lead to 20% less utilization of SHC.
Jeff: Dispensaries are underutilized. Increased utilization of dispensaries may bring in more people.
After break Ben Jesse and Matchigo Talley arrive from Kosrae.
We moved through goal two and three in good time. We are moving on to goal three. I am omitting general discussion to save battery and am making jot notes on the matrix directly. Thus my first day notes are highly incomplete.
Hiroshi Ismael: Nursing school extension to serve as referral center?
Dr. Kennedy: Neth recommends $ to COMFSM for nursing, our share. Our students are going elsewhere, MOC, RMI, CMI nursing, so that money could go to Chuuk, That was our thought.
Jeff: Embassy also mentioned interest in helping develop nursing school. Not yet reached a point... Japan will review. We can propose, they still get to say whether they think it is a good idea.
John: can funding be diverted to state to help sewer, water, etc.
16:47
Hiroshi: Goal three is really a mandate to health educators, to educators, and not necessarily a mandate on public health departments.
Comment added in: exercise plus nutrition.
17:07
Day two
2004 31 March 0929
Covering yesterday's decisions.
Kosrae wanted to include construction of new hospital. We also discussed the extension of the Chuuk hospital. No recommendation will be made, only some diplomatic language. Hiroshi had noted a need to do homework on this one. Some 300K remains owed on the land purchase.
COM wanted to change decrease obesity to increase awareness. Other changes included 3.5.1 SAMH provision might require counselors in every school.
Wisener: infrastructure comments...
Dr. Kennedy: construction of a modern hospital facility... Dr. Kennedy reads from the infrastructure plan that specifies a referral hospital and hospital building plans.
Valerio: Construction of a new hospital, but can funds from health sector build a new hospital? Can we recommend?
Jeff: Infrastructure today: we need some people to go over there this afternoon to the infrastructure sector to carry our recommendations over to them. How are we going to report on the medical referral center?
Hiroshi: These people are waiting for us to give a recommendation. This is not a recommendation, We need to lay in place the infrastructure: land is available, people are in place. All of these are lacking. The cost analysis has to be undertaken (and must save 75%). Get Chuuk, if Chuuk wants the hospital, get Chuuk to buy the land. Then we can support the referral hospital.
Jeff: The concept is good but there grey areas that are not ready yet.
Hiroshi There is lack of staffing and other things [that we do not have in place yet]
John G.: Will having this hospital take care of our needs.
Dr. Kennedy: Having a national hospital is not going to stop us from sending people to the other hospitals. Can we take care of it, can we run it, if Chuuk cannot have referral hospital, then why not the other states host it. It is not a must [that it be built in Chuuk] but the nation needs one. Is it going to take care of all referrals. To bad Dwight Edwards is not here – national health insurance. Chuuk owes something like eight million in referrals. We give them five years, ten years down the line. If they are not referred they will die.
John: It is not really the question of having a referral hospital? Will the cost be reduced by having a referral hospital? Will the sacrifice of x million dollars to support a referral hospital really benefit all 100,000 people.
Valerio: Referral continues to be a major budget drain. We need a plan. Having a referral hospital will not end referrals. There will be complicated cases. Some might choose on their own to go elsewhere. We need to deal with the issue now.
John: Usually this is state of development, one can create a monster, one issue that you health people have is there is no way we can get... is there a... we would have money to leave (live?) it is going to be painful. If you made a referral hospital and you cannot put a tag on what you can refer then you do not know what will be referred. Even in the US not all hospitals deal with all conditions. So we are simply adding a step to being referred.
What services do you want to offer.
Hiroshi: The decision to have a referral hospital was made by the leadership. Our job is to make a recommendation. For our leaders to consider. Number one: no cost analysis. Number two dept of health should review type of services are currently available. Come forth with recommended types of specialists that should service and meet the demand for the referral hospital. Get Chuuk to provide land if that is where it will be. Get all this package together and then relay it to the leaders. If it is not feasible, then fine, do our job.
Jeff: Can you read what is there now? 2.2.6 Chuuk recommends extension to Chuuk Hospital for referral.
Hiroshi: Maybe you should recommend further work by the department of health.
Mark: There is the land, the building, but then the stuff that goes into it. The internal infrastructure is the hard part: water, power, intensive care specialists, oncologists, technicians. Is the concept, maybe an incremental approach focusing on functions rather than facilities. Aiming for attainable services. Orthopedics and that package, realizing that a lot of other stuff would not get done. Still would be referrals. Not a referral hospital per se, but modules of functionality.
Jeff: That makes a lot of sense.
Bob Spegal: That is a good approach. You also need to look at state hospitals now, look at capacity of hospitals at the moment.
Valerio: This would be part of the study. But we need to recommend to the assembly the idea of a referral hospital.
Eliuel: I would like to add feasibility of having a referral hospital, we should also include other options. Contracting out to the private sector no matter what we do the cost will still be borne by the referring state. The cost will not be free. We need to look to the private sector. Can we establish sustainable health insurance? We should look at referral in health insurance and how that might help finance the referral facility. If we have internal concern about lab facility maybe we utilize internal lab facility (national lab?)
John: One thought to think about. There are direct ramifications. Every time we sit, some state usually it is good to keep in mind and we start to manage this should be in the background. Having a referral hospital will have an impact. We have not studied it. Because of referral, what happens is the state hospital deteriorates: (skills not used become rusty, if skills get used in referral only then state hospital may lose skill sets?)
Jeff: This leads to next section. Goal number four. Sustainable health care financing.
1017
Marcus: A need to improve services on island. Cost is a reality, especially referrals. 25% of budget for referrals benefits 10% of the citizens. How do we creatively construct a package for on-island health services. We need to charge for services. We need to pay for off-island referrals (not incur debt). What would be the stable mechanism to finance our health care? Health directors worked with ADB consultant. There were thoughts on activities. Recommendations to be made. recommendation
Hiroshi: You do not have sustainable program, you have insurance run by national government. The nation has no sustainable health care, if anyone has one they need to come forward with one. Cost of treatment is going up, second we have allowed to abuse the hospital and expect free treatment. Insurance is only for a limited number of weeks. We need a financial mechanism that can be sustained.
Valerio: 4.3.1 Do we have the authority to enact laws, is this relevant? (Law changed...)
Ben Jesse: We can recommend, law makers make change.
Valerio: this is too broad to me. We need to be specific. Enrollment in NIP might be made mandatory for all government and private employees.
Bob: There are people who are not in government or private sector, the half of the population not in the cash sector. What about them?
Valerio: How many government employees?
Dwight: About 60% of government employees are in, 20,000 total enrollees. 20K is total. 3500 government workers are in with dependents.
Jeff: How do we include the rest?
Bob: You need to include all FSM citizens in an insurance scheme. Insurance cannot include sick and well people. Only the sick ones are in, so it does not balance. Primary care should be free: get people cured at early stages.
Dr. Kennedy: Arthy mentioned Kosrae taxing regarding primary health care. PHC should be affordable.
Jeff: That point is taken.
Amato: We need standardization of hospitalization with regard to cost. Difficult to collect all the money for the services. One option is insurance. States are trying to set fee schedules, while insurance has their own schedules. How can we determine the fee schedule? We do not have the record. Each state can itemize their costs so we can understand the costs. Yap is very successful.
Wisener: We are doing that at our hospital.
Bob: NIP does not pay on time and this is a problem. Four months or more late in paying.
Marcus as board chair of NIP: I am in dark on this. 4.1.4 is the one that should be our focus: NIP policies are agreed to both by state and national government. Maybe some kind of policy change can be done first. Not sure how to include all FSM citizens are in the plan. Policy change required? Or a law?
Bob: You might need an additional plan to complement that one.
Valerio: What is the structure of the board with state representative?
Jeff: Yes.
Wisener: NIP is doing well and improving. We need to make it better. They are autonomous and this complements our outputs. Pohnpei state is also looking at a plan to include Pohnpei citizens. Maybe the state can give money to NIP (and have NIP administer the Pohnpei state insurance plan...)
Hiroshi: There are four outputs all of them regarding NIP. Bring this up to them to honor them, let's combine them, so there are not six.
Jeff: Good point. Are these good one year outputs.
Dwight: Change management. Change of management has been addressed. New law created a board of directors about five months ago. They have done a great job. Before plan in deficit two million. The board has submitted changes in the plan and working with the state hospitals to improve the plan. We also know overcharging is occurring. We have too many sick people in the plan. Pay out exceeds pay in. Activity four can solve some of this: mandatory participation.
Jeff: So we need to modify the grid to not say change but maintain...
Vice Chair HEW (Chuuk): There are other private health care working in Chuuk state, e.g. Moylans, I agree with the idea to have a single insurance plan. Some employees are paying into two or more plans. On the other hand national health insurance has limitations, hence paying into two plans. Universal or one health for the nation. But then 4(vi): privatization of health services. Is this contradictory? Universal national health and privatization? We should privatize the plans and let employees choose the plan they want. Right now there are confusing overlaps between policies. In order to change health insurance in Chuuk we have to modify constitution in Chuuk, it is mandated there. What do we want, uniform for the nation or let people choose. I think for one and two perhaps we look at them.
Jeff: Perhaps I can respond. The more you have in the plan the better the insurance. If, say, Yap went separate, then it might fail. More is better. If the whole FSM has one, there is a chance it will be better than state by state insurance plans. 4(vii) privatization refers really to the hospital: privatize security at the hospital, food services, custodial.
Bob: Activity 4.1 you could put the word health insurance schemes. Sometimes health insurance is used to cover major illness. But Kaiser: they are a health maintenance organization. The health insurance works to keep you healthy. I do not know if we can find one that can serve both purposes. At the PHC level the more you can get people in early on. Health insurance schemes.
Valerio: 4.1.4
Hiroshi: national health insurance, but we need all states on board. For universal we must be combined. We need to be together.
Dana: HMO model? Thinking beyond insurance? Pay people to maintain good health? Or differentials in insurance rates based on lifestyle choices?
[Side discussion during a separate break: the American insurance model has never led to universal health care, but there is clearly a social impetus for such in the FSM. This means abandoning the American insurance model and adopting government based health care as is found in Canada or Australia. Paying for access to health via taxes – universal health care does not make money hence insurance companies cannot support such a system. But this would be a fundamental change. American advisors with their American upbringing and thinking are unlikely to help the nation move to another model, another way of thinking about the financing of health care]
Bob: Scandinavian model: must include health maintenance in activity 4.1.
Arthy: Nobody is denied service at the hospital. This in itself is universal coverage. What we need is the money.
Jeff: Health is business.
Jessica: Europe or Canada. You are not turned away from the hospital, but hospital is not getting the necessary resources. We are saying we want universal coverage. You cannot do it without government help. If you go private, the US model, you do not get universal coverage. If you use a Canadian model with government involvement you get universal coverage.
Hiroshi: States cannot go it alone. Universal is worth pursuing. Kosrae's desire for a new hospital: predicated on universal coverage in Kosrae. Everyone can come in and access at a price. Two we were advocating Kosrae as a retirement haven. A new corporatized hospital will have a standard to meet the needs of retired Japanese and American citizens. That is a concept we are pursuing.
Jeff: Not only Kosrae, but Dr. Nowell in Chuuk has the same dream.
Vice Chair HEW Chuuk: Only the government and private sector are insured. About 60% of Chuukese are not covered by national plan. They are fishermen and farmers, artisans. They are not covered. We need a scheme that can include all the people of the FSM. Our constitution requires a Chuuk state insurance plan.
John: The plan was to work with national health insurance. Data overload a problem in the original plan. Plan was to look at national health insurance.
Dr. Kennedy: Chuuk health care plan does not mean Chuuk does not want to join NIP, we just need a sustainable health care financing mechanism.
Eliuel: Add more explorations be made as to what is the most feasible. How can we economize. Some states want to establish state based insurance. So national backed off from studying the matter as to what is most feasible.
Jeff: We need to study the national situation in regards insurance.
Hiroshi: For drafting purposed we need to look at certain words. The use of the word "poor" might not be appropriate. It could be reworded and moved up to 4.1 – the key word is universal coverage for all people. The safety net.
Mark: Does that need a feasibility study? The safety net is good idea, but feasibility?
Break
1123
Change the word policy into law in activity 4.2
Bob: 4.1.4 For the entire summit we are talking about agreement between national and state. 4.4.1 seems redundant.
Unk: 4.1.1 is still there?
Bob: 4.1.1 to 4.1.3 could be squeezed together into a single output.
Jeff: Wisener, can you report on this?
Vice Chair Chuuk HEW: 4.3.5 should be modified.
Bob: Move 4.3.5 to 4.2.
Valerio: Move 4.2 to 4.1 has an output.
Hiroshi: 4viii should be rewritten. Presently reads "off-island referral decreased to 5% of budget." But that is not what we tap. Should refer to "of total budget" Your aim is to go down.
Marcus: One view is to reduce what we spend, the other for it to not exceed 5% of your budget.
Wisener: That's a lot.
Jeff: Baseline is 13% FSM health budget.
Mark: Output 4.4.1 The problem with referrals is there is a fixed pot of money. We need to break that dependency where referral is connected to overall budget and link referral to taxes on tobacco and alcohol. So anytime you increase referrals you increase tax on tobacco and alcohol. Taxes on alcohol and cigarettes should be raised and that should be a financing mechanism for referrals. And referrals should be limited to that.
Hiroshi: We have operated with x amount of dollars for referrals under Compact I. We need to reduce.
Mark: A proposal to eliminate referrals as part of the health budget. But then a proposal to finance referrals from alcohol and tobacco taxes.
Hiroshi: Under 4.3.1 what is our goal with respect to changing laws?
Arthy: This should be a goal...
Jeff: Maybe we can focus separately on referrals from a separate budget. One way would be a tax such as a sin tax being used for referrals. For referrals or to build up the state hospitals to handle referrals. And then Hiroshi wants to put that under 4.3.1 to change the law in all states and at the national level.
Bob: Is that also 4.3... You ties those two together you generate a huge awareness. I like the tie in. That was suggestion for the Pohnpei state plan at one time.
Hiroshi: If we propose termination of referrals is tantamount to saying no more betel nut in this nation. What we are stating here is 5% of total budget. But it is less than 5% of total budget now. We should decrease to 5% of what we pay now.
Jeff: We need the baseline.
Hiroshi: There is no budget for it.
Marcus: So if you spend 300K, then you have to reduce it by 5%. Or total elimination of government financing of off island referral.
John: Taxes are an issue. The probability of it going through. '
Jessica: A compromise to propose to reduce referrals while at the same time lobby for a sin tax to cover extraordinary referral. There are not too many people being referred but people being sent who do not need to be sent.
Jeff: While reducing current to less than 5% then we also look to lobby for the sin tax.
Hiroshi: A complement not a compromise. We can leave the reduction at 5%.
Valerio: Medical referral is 20% of budget.
Marcus: So Hiroshi is saying reduce by 5%.
Valerio: So it means 15%
Aaron Sigrah: The suggestion is not 5% in terms of financing but in terms of per capita?
Hiroshi: 5% of budget. Over a twenty year plan to reduce by 5%.
Bob: Government will not cut referrals tomorrow. It will be gradual. During that time we can work on building internal systems. There will always be some cases that have to be referred. I like tying it to sin taxes. I look at my cigarettes. If my cigarettes go up in cost by 50% and then I read in the paper that referrals were up 50% then I know why my cigarettes cost 50% more. I like that tie in.
Hiroshi: When you adopt this outcome as it is. What is your output?
Side discussion: Kosrae working on 2% sin tax. Has passed first reading in legislature.
Bob: 4.1.2 Funding. How does this fit in? Health and sports being promoted is good. Having health involved is good. But how is private sector funding fits in with other things here. Am I missing a tie in. Should be in three.
Marcus: Health promotion for youth and have some health clinic aspect to it and that funding would be privately sourced. Compact will not fund this.
Bob: Feasibility study to consider additional private sector funding and then list these things but not limit it to these sport activities.
Hiroshi: Especially for diabetes we need to implement the concept. We are talking about promotion of health activities that relate to living healthy lives. Sport, recreation, fitness.
Jeff: Which means it relocates to goal three or one.
Bob: 4.4.2 be reworded to consider private sector funding for these activities. So we are looking for funding, OK.
Aaron: 4.4.1 and 4.4.2 talk about health promotion. 4.4.1 addresses what, do we know what this is, what is the highest number of diseases, of whatever diseases, sin taxing is assuming lung cancer are the highest. It is important to consider other foods. A sin tax on turkey tail, for example. We cannot really control what people eat, but we can have an impact by doing these things, putting these things in place.
Jeff: Yes.
Aaron: MSG in our food, you go to restaurants and...
Jeff: Thanks, Let's move on.
11:57
Dr. Kennedy: 5vi and 5vix.
Jeff. Thank-you. We will delete 5vix. They are duplicates.
??: Maybe Amato likes that one. [laughter]
Dr. Kennedy: By the time we finish the training we are out of our positions,
Jeff: OK, if you have only one year more we will not train you. That is a part of unforeseen circumstances.
Bob: To address this, we would need much more major reform. Not just an appointed position. A permanent position. Like some countries where there is a political head and then a permanent head under.
Bob: Marshalls has a permanent secretary for health and then the minister. The person replaced every four years is the minister.
Marcus: What is being recommended?
Nothing yet.
John: Director should be...
Jeff: Can we add on maybe the permanent director to provide continuity.
[Training should not just be of top replaceable brass but also of secondary tier etc to ensure continuity]
Jeff: The idea in this goal is that we never reached a point where we made informed decisions. We are not using statistics to make decisions, we need to improve the gathering statistics. While collecting the data and statistics we would also be improving accountability. That is the kind of broad intent we had with improving resource allocation and accountability systems.
Valerio: If a primary health care or preventive services we tell about it.. over 70% is going to curative and not preventive services.
Jeff: You spend a lot of money on diabetes, so that is what you focus upon. Statistics can justify allocation.
Hiroshi: Is there a report on the types of diseases being referred outside? Do we have those statistics.
Marcus: The answer no, they do not share.
Dr. Kennedy: We can report number of dollars versus types of diseases referred out.
Hiroshi: Then in 3.4 we should... we are talking prevalence and causes and yet we do not know.
Bob: I was able to get that information by going to the insurance and getting it, but with the new board I do not know if that is possible. I could get this from all insurers. So 4.4.1 we could put this.
Jeff: OK.
Valerio: We need to be more specific. Only the training of hospital administrators?
John: Improve staff development? Would that align better?
Jeff: The idea is to use data [to drive decisions] and then the decision makers can use that data to make decisions.
John: Will the plenary understand what we mean? If not we may get the same thing at the plenary. We might end up with a lot of questions.
Bob: Maybe the word allocation is misleading. I know what Valerio is saying. If you look at the books you will that all of primary health care is funded out of US federal grants, we are not spending any of our money in primary health care (PHC). We talk about PHC but our money is not where our mouths are. We might say that the states have to put a certain amount of money into PHC. We do not put any of our own money into PHC. We need to put our money where our mouths are.
Hiroshi: I think that we are heading the right direction. Our history is that each state has an operation budget. Now we moving into an area in which everything is ours. Sector by sector funding. If we are prioritizing PHC, then let us put our money there. At the same time we need to put money into secondary. How do we allocate resources. Under our BSS [Basic Social Service] system we are going to upgrade all of our PHC. But we are handicapped at the start as half of the nation is not covered. We want to invite our brothers in Chuuk to come in and participate. Allocation of resources should be such that we concerned that we are not meeting standard in Chuuk. We need to train our health aides to go out. You have 2.3 million... how come you do not use it.
Jeff: Allocation makes sense.
Dr. Kennedy: Number five, resources allocations. I will not answer about the BSS project. We need to convince our leaders, we need that primary health care infrastructure. We have come a long way. 17 years. Complacence for us. We have seen the model in Yap and that is the model to follow. We can look back at what went wrong and the problems that we had with resources allocations and in the federation Chuuk always came out disadvantaged. National government took half a million dollars, Chuuk took 4.71, that is percent of the budget for whole FSM, the Chuukese got 80 dollars per person per year while Pohnpei has 173 per person per year, Kosrae 170.6 per person per year. And the fortunate brothers and and sisters in Yap [were] allocated 2 million which is 38% or 256.35 per person per year. Reviewing back over first compact, the delivery of health care [in Chuuk] given the geography, I am not asking for fix. But we must think of us as FSM and not think of us as Chuuk, Pohnpei, Yap. We really need to look at expenditures over last 15 years. That can testify whether we live a better or improved secondary health care. When we are in this room we are not from Pohnpei, Chuuk, this is an FSM package not an individual state package. The draw down is into five accounts. If Chuuk gets their cut, then maybe they would not share but I am trying to get something for the nation.
Eliuel: These are the facts for all these years. But gentlemen, we are in a new era now. This is second compact. This is the first time we have an opportunity to plan what we need. The compact is very generous to give health and education priority. Health is a sector is falling down. It does not say who gets what. It is up to us to plan. The first priority must be primary health care. Budget accordingly. Put money into dispensaries. Do not depend on governor, do not depend on congress, put money into dispensaries. If doctors are not well trained, put your money into there. Put your money where you need it. Do not mix up primary health care money with secondary health care money. Do not put them together. That is where you lose your needs. Hospitals are for doctors, doctors are [naturally] aggressive in treating patients. [Dispensaries may be just as effective, especially if intervention is earlier, and their less aggressive approach will cost less.] If your dispensary needs supplies then this is the time to support. Chuuk received about 4 million, Pohnpei received 7 million. What Chuuk got is what Chuuk decided. What Pohnpei got is what Pohnpei decided. Work closely with your budget people. If your budget is low, then your money is coming to you. [I missed some critical words there] Pay close attention to your budget. Work together. We put emphasis in primary health care which we never did in the past. We cannot omit secondary care, it supports primary. Let's not complain, let's say "I made the mistake because I did not put the money into it."
Matchigo: Training for nurses was identified as a need. Very little discussion. I am not sure it is in other sectors. I want to see this included in the matrix.
Jeff assigns John and ____ to infrastructure sector this afternoon.
~~~
31 March 2004 14:19 After lunch
Jeff: Introductions. Moses from Yap. Expecting secretariat of SPC later.
Raconteur: Under goal one Kosrae wanted to see insertion of breastfeeding and the establishment of community health profiles. Kosrae wanted the word dispensary replaced by dispensary/health center.
...
Jeff: There is an international convention on [tobacco] we should support.
: Child health care. MCH.
Jeff: [I would like to introduce] Miss Lou Pangelinan, director of the secretariat of the pacific.
Lou: My apologies. I just arrived from New Caledonia. I hope you do not mind my joining your sector.
Jeff: We have gone through the matrix and that forms the basis of what we are talking about and now we are going back to review what we talked about. I hope that you can follow along.
Lou: Do not worry, I will follow along.
Hiroshi: One of the indicators that is lacking in this to control or decrease infant mortality rates. If we put it under 3i or 3xvii.
Jeff: Thank you. That is a really good outcome measure. Still I am trying to figure out if it a good idea to use it. It will take a long time to see the impact. But I think we come to a point where we have been asked to rank this as an outcome issue. Marcus?
Marcus?: Basically, you look at all the goals and nowhere is there any mention of mortality figures. That has been, that would be an outcome measure. We know our infant mortality, in reality you want to measure progress. Those would be important indicators. But it is not anywhere in the outcome measures. I am not sure how to get to that point. It was recommended during the working process. One indicator would be to run from the baseline indicator of 2002. Its not – it s about that out there for us in health. That important indicator is not there.
Hiroshi: I think we can come up with incidence of diabetes and use it as an index on the outcomes.
Dr. Kennedy: The infant mortality rate, the diabetes rate. Prevalence rate is about 25%, so 25 of 100 have diabetes. High blood pressure is about 35%. These are international measurements. These are indicators that are international indicators and have meaning for everyone everywhere.
Valerio: How different is an outcome from an output?
Jeff: Outcome is long term, broader. Output are things you can see on a yearly basis. Short term measurements. Outcomes are long term and kind of broad. Infant mortality is an outcome measure. It has a lot of things that affect it.
Bob: These outcomes have a lot listed. Some are specific, VAD, others are broad in nature. As we talk about indicators, maybe an output could be a set of indicators we will all use. MMR (maternal mortality rate) and IMR are both necessary (infant mortality rate). We need to determine what are reasonably important and can be recorded.
Jeff: We can make an activity to establish those common outcome measures and determine baseline data, baseline values, many of these indicators we do not have the baseline. Perhaps goal number five.
Bob: Under 5.2. Accountability systems. MIS.
Jeff: It will fall nicely there. Only when we know where we are can we move forward.
Hiroshi: One area that we need agreement on is [the need for baseline data]. [We note] that diabetes is under study by University of Rockefeller in Kosrae. In the 45 and older close to 60% are diabetic. It is probably the same everywhere. We have benefited from the data. We should have that kind of data somewhere. [We should have the gathering of health data somewhere on the matrix.]
[Editor: underlying this is the theme in supporting documents that data decisions must be data driven. There was briefly floated the idea of improving all hospitals as a way to reduce referrals. Beyond improving all four, was the idea that instead of a single referral hospital, different hospitals might specialize in skill sets that benefit a smaller subpopulation of the FSM. Thus one hospital might specialize in advanced care for diabetes, for example. Understanding the disease distribution would be critical to these efforts. Knowing that Kosrae is number one in diabetes, with numbers varying from an estimated 11% of the total population to over 30% of the adult population over 35 years old. At a more detailed level I have heard that Malem, Kosrae has 40% of their over 35 adult population with blood sugar levels indicative of diabetes. This would rival Nauru. Knowing this, the dispensary in Malem might be charged with watching blood sugar levels closely, working to treat cuts and other possible infections early, and other proactive diabetes defense mechanisms. They might also undertake a special exercise program for Malemites. In other words, data could drive good decision making. Baseline and ongoing monitoring data are both needed.]
Jeff: Under goal three? Raconteur is to now go through goal two.
Hiroshi: Is Kosrae hospital in there?
Dr. Kennedy: to improve on island facilities to reduce and minimize off island referral.
Hiroshi: When you [Jeff] present it you have to present that this is a rather sensitive issue, be diplomatic.
Jeff: I want to be diplomatic and yet tell the truth.
Hiroshi: What we discuss during this meeting, put on this table,... [is only for this meeting?]
Raconteur: Strategic goals in promotion of health.
Is this where IMR and MMR go?
Ben: No, under five.
Valerio: Are we not repeating the compact with that promotion. "Emphasis has been given to several public health programs?"
Jeff: It is like the health sector reminding itself. Sometimes we forget. Right, John?
John: Most of the time.
Jesse (Yap): I have not seen school examination for service providers, teachers.
John: Physical examinations for teachers. Maybe physical examination something that I can help us find out who needs intervention before referral.
Arthy: Maybe under 3.1.4 school programs.
Wisener: Good to have the health workers in here as well.
Jeff: Call it 3.1.6?
Bob: Maybe in 3.1.3 extend it a bit to include annual physical examinations for every student. And then maybe covered employees. It would be nice to have an exam for everyone in here and have it tie into a reduction in your health insurance.
Jeff: So extend 3.1.3?
Eliuel: Consider the following: for the time it is the responsibility of the agency to recommend the kind of examination. If we put this in then health may wind up paying for examining all of the students and teachers. Is that the right way to approach it? Services will be available, but those agencies have to have input into the services that would be provided.
Bob: For the schools the schools would handle it. But for other organizations they would have to decide.
Mark: There seems to be a consensus that the whole population have access to health, not just the faculty in the public schools. Fishermen, subsistence farmers too.
Bob: We felt everyone should get a physical examination, it would cost less than waiting for a disease to present itself. Getting physical examination for everyone would save money. Catch things early on, especially in the school children.
??: What about whether they [teachers, restaurant workers] have AIDS?
Aaron: All people [on Kosrae] who want to get married have to pass a physical examination. That is one way to get data.
John: If we want intervention, do we get physical examinations? What about us? No one in the room, maybe one, the runner, but if we want the public to get physical examinations.
??: Does insurance cover physical examinations?
??:Yes
Bob: If you build a health examination into your insurance scheme, then insurance will save money. So it benefits the insurance scheme as well. Maybe that can be done for universal coverage: coverage requires a mandatory physical examination. You are not covered until you show up for physical examination.
Chaine: Last year Pohnpei had two cases of tetanus, first in many years. The shot is six cents. As part of a physical examination we should dictate that immunization records are looked at.
Aaron: There are always constitutional questions surrounding mandatory physical examinations.
Jeff: JP is asking we check the record, those kinds of things. Is tetanus up to date? [In the last ten years]. Would this be a problem?
Matchigo: No.
JP Chaine: Not a problem.
Bob: A physical examination should include all of those things and should not include those things that it should not. And make it cost extra for lawyers. [laughter]
Jessica: The recommendation on being overweight, the health risks need to be added. Number 3. [It reads "Increase public awareness of being overweight." It should read] "Increase public awareness of health risks of being overweight.
??: Nutrition survey. Do you think we should have an output to draw up nutrition action plans for the nation. A new output at the nutrition survey. Where is that, the national nutrition survey. 3.4. Output 3.4.5?
Bob: Do we need another survey?
Hiroshi: we should bear in mind that the division of compact funds is allocating less to national government. Lets not rely on the national government as we did before. Go easy on it.
Jeff: Yes, and I also noticed that he is trusting that sources will be coming from SPC.
Lou: We are pleased to provide technical support and assistance. This process is important at the national level. It is important for indicators to be agreed upon. The region establishes sets of indicators that your governments agree to. Three to four years ago there was a goal to reach regional targets [for tuberculosis]. [These were set at a] meeting at Noumea. These meetings at the national level must be reflected at the regional level and then globally.
Jeff: National government does not have that much money. Do not add more and more to national government.
Ben: Let the states work.
Bob: When we are done we should check and see what we are loading onto the national government. The funds might be decreased.
Arthy: My concern is that the program problems...
To include nutritions to focus on... [ air conditioner above me has come on and is noisy, hard to hear clearly. I shift over and miss some of the conversation as I readjust my location. This puts me next to Matchigo Talley.]
Bob: Establish a national nutrition program and the target must be NCDs and MCH.
??: Include a "youth nutrition" program?
JP: Page five, 3ii has 85%. It needs to go under output and at 95% Two of our states are above 85%
??: Minimum is all right.
JP: we will never get 100%
Hiroshi: You must always look at Chuuk.
Jeff: The outcome must reflect an average.
JP: 85% of all two year olds will be immunized.
Mark: This is a how long plan? What about 90%? You need to get above 90% to really end the diseases. 90% over twenty years is not unrealistic.
[At 90% you can get, I gather, de facto eradication of the disease.]
Jeff: It is a stretch, but you try for 90%.
Marcus: 85% is a floor.
Hiroshi: Asks the Chuuk outer island (OI) cold chain question.
[This discussion requires some background. Vaccines have to be refrigerated all the way to the client. Keeping a vaccine cold is referred to as "maintaining the cold chain." I learned in separate conversations that oddly enough the presumption that the cold chain is a problem for the outer islands is specious. Sounds true, but is ultimately false. The cold chain can be preserved long enough to get active vaccine to the outer islands. Gas powered refrigerators or last leg cold storage chests have proven effective globally. Africa has far less accessible locations that get vaccine. The sad truth is that it is the family living out back of the dispensary that might not be fully vaccinated. In the outer islands people line up for the injection and you can routinely vaccinate 99+% of the two year olds on an atoll. But rural Kitti has something like a 73% vaccination rate.]
JP: There is only one vaccine that can be taken out of the cold chain.
Hiroshi: Seven days no cold chain.
JP: Chuuk can get to anyplace in less than seven days.
Hiroshi: It goes to Namoluk, then to _____, and on to ______.
JP: Gas refrigerators... the OI are not a problem. In Pohnpei the OI are better immunizations – the people line up. The problem is closer to home. Rural Pohnpei.
Dr. Kennedy: You may have a high rate, but when you do a study of blood antigen you find out it is low. The immunization rate may be high, but the break down in the cold chain means they got a useless shot.
JP: The problem is the lagoon islands: 70% of OI Chuuk immunized, 30% in the lagoon.
Bob: The outer islands are not the problem. I would shoot for 95% across the board. You say 85%, if you hit it, then the politicians may cut your budget because you hit your guide. I would shoot for 95%.
Marcus: The outcome is long range, the output is short term.
Jeff: Let's vote, 85%, 90%, or 95% at the end of twenty years... We voted for 90% across the board.
[side discussion with my neighbor who was nearly a lone vote for 95%] Kosrae at 98%, still reporting 95%, [but we have already achieved 98%]. The barrier to the last 2%: immigration and religious issues. [one religion in particular does not participate in immunization]. I turn back to the group discussion.
Amato: Monetary out break.
[Dwight rises to leave, I follow him outside. Outside discussion with Dwight on possibility of insuring our students. Dwight is more than receptive. He awaiting numbers from Danny. How many students per term. Jazmin and I note that this probably looks like 2500 or so system wide. Danny needs to get numbers to Bong – Jazmin knows this person – so actuarials can work on rates. ]
[I return and wind up chatting with my neighbor again. I am so easily distracted.]
15:29 My head and fingers are back into the mix...
Insurance discussion ongoing.
Bob: The wording here needs to be focused. Feasibility for health reform, that is a very broad term. We need to reword this to make this clear. Health insurance reform. This makes if a little bit confusion. If we are focusing on health financing and health insurance then I feel better about what this means.
Dr. Hedson is introduced.
Dr. Hedson. I am an MD and invited by the acting director to share my thoughts. Marcus ... [A young woman bends over me to pass out a hand out. I become distracted again. Reminds me that the problem for the participants in the gender sector is actually a problem one gender has with the other...]
Bob: You cannot under state codes deny service on basis of a lack of an ability to pay. None of this helps us improve our health care. [None in this section]
Mark: Financing is complex and technical and lots of consequences. We need to think this through. Do you need a national payer or a competitive environment or insured plus a government safety net. Too complex to tackle here. Maybe we assert a desired goal of universal health access and then tackle in another venue the issue of how to achieve that.
Jeff: So what is the modification?
Hiroshi: And will responsibility for carrying this out be added to the national government?
John: You can find ways to assist health care with minimum cost.
Jeff: Remember BSS is assigned to review insurance.
Hiroshi: Have we cleaned up that insurance section?
Marcus: I do not want to touch the legal [aspects].
Bob: We do not want a feasibility study, we want them to work it out. For health insurance mechanism financing reform including a safety net for uninsured. We are identifying this as an issue.
Jeff: Shall we move on? Lou is leaving now.
Lou: My apologies. This has been a learning experience for me. I think I can see where interventions will lead. I look forward to helping implement these things.
Josiah lets her out.
Jeff. Let's go on to goal five.
Ben: Can I ask about four. To develop a sustainable health care financing. One way is to privatize some services. How are we doing on this under 3vii?
Jeff: What is going on in Kosrae?
Ben: We have not privatized anything. We proposed. We proposed to this level but nothing materialized.
Pohnpei: Privatized the housekeeping, janitorial, security. Looking into other possibilities. May include our cafeteria, our pharmacy, those areas. We also have private clinics as well. That is one way of privatization. Medpharm, Genesis, and Pohnpei family clinic.
John: Security, janitorial services, cafeteria.
Dr. Kennedy: A few private clinics, mortuary is partially taken care of privately. Would like have same with housekeeping, feeding programs. Under compact II the basic patient feeding program funding increased. Security is being handled by department of public safety. We would like to, our major concern is the, how to make local revenue. Generate local revenue. Medical supplies and equipment funding is... we have some collections under FSM insurance plan and from Chuuk health care plan. We have a little of collections but not the amount we are spending for medicine.
John: Privatization... we do create jobs in the private sector while freeing up money for other uses.
Jeff: Let's move on. We are on five and it is almost four.
Valerio: Replace resource allocation with capacity. Capacity building. I am thinking that if we change the resource allocation it will be the actual thing in the outputs.
Jeff: Your proposal is to improve capacity and accountability systems as the retitling of goal five.
John: I was also having this question, it seems like the title is focused on money. Maybe capacity building is a plus because it is mentioned in the compact.
Jeff: Silence is a good sign, it means consensus. It is a Micronesian way.
Dr. Hedson: Instead of improve, stratify resource allocation. Or strategize resource allocation.
Hiroshi: While I agree with the rewording, while we talk about capacity building we are talking about people dedicating themselves to a profession. We are not addressing nursing, paramedical, medical. We should improve capacity building that touches other professional staff other than administrators and managers.
Jeff: What was that? 5.3?
5.3.3.
Jeff: It is an insertion. There was proposal from Dr. Hedson. Were you serious about your suggestion? We changed resource allocation to capacity building. No more resource allocation. Any more on that goal. Silence means...
Dr. Hedson.... consensus. [laughter]
John:
Dana talks. [If we are retitling from resource allocation to capacity building, then does the training of new capacity, new nurses and health care professionals, move from activity 2.2 into goal five? Are we not in the business of building capacity?]
Jessica: 5.3.3: Nursing training. Preservice. This is an insertion for five.
Eliuel: All this time we have talked about a nursing school at COMFSM. COMFSM is reluctant to start up but no money. Then there was PREL money, but then the application was not submitted in time. So it was not considered. We had WHO made a feasibility study on nursing the strong recommendation is that we should have their own nursing school. FSM is more appropriate than even Saipan. Second is that assessment every year we will have a deficit of eight nurses per year starting in 2000. The cost also that makes it very difficult. But then maybe we can look at other options like create it at a hospital and use health personnel to do the training. For your information, the nursing school was priority and dental officer training but now there is a school in Fiji so the priority is reduced. We have a nursing school in Marshalls but not working out well for our citizens. Very few going into that school.
Jeff: Thank you. We know we need nurses. Starting one is in the minds of many. National and COMFSM have been talking about this. If this groups feels this is important, then great. We will include it. A strong feeling to have a nursing school. Raconteur will find a place for it.
Arthy: Also relating to nursing we have growing problem with the shortage. It is not an attractive position due to salaries. Many of our nurses are comparing salaries to Pohnpei, Chuuk and Yap. While they feel they are doing the same things, they are not being compensated. This might be a factor that is contributing to the decline of young ones going into nursing. If we can see how we can come up with policies to address this, to improve the situation that exists.
Wisener: Not a matrix comment, but a policy that would address the difference in the salary structure of the health professionals in the FSM. Have the policy makers address this. Maybe it will be more costly for the FSM at the end of the process.
Mark: Can I put a hat on? I hear differences in salary schedules. What I see as a bigger issue is the salary differential with government positions. Nurses leaving to join other government workers in better paying jobs [with easier hours].
Dr. Hedson. Thank you I wonder if this body has discussed the workers to physicians ratios between the states. What is the acceptable ratio?
Wisener: When we address what I mention that will be one of the elements. You will look of ratio of professionals.
Matchigo: Workload [is a cause of nurse departures from the hospital].
[Jazmin and I had an earlier side bar noting that none of the nurses COMFSM has produced are still working in the hospital. Of recent trainees, two joined private clinics and one left to at public health for more pay and no shift work. Jessica notes that one has to overproduce nurses to get the few who remain in the hospital and that one has to find ways to accommodate the legitimate family needs of Micronesian nurses. They cannot work night shift every night. Night shift work has to approached from a part time perspective: a worker might not be required to pull a full eight hour night shift. The night nurses are truly unsung heroes of the health care industry. It is at night in the pediatric ward that childhood fevers tend to spike, and in the dark of the night there is only the nurse and her skills to comfort the sick child and the worried parental caretaker. I know, I've been there on the parental end.]
Wisener: How many doctors per capita by state?
Bob: 2.1.5 Practice established standards... we could insert in here appropriate to the population.
Jeff: Whenever someone discusses ratios, WHO has guidelines on what they think is appropriate.
Eliuel: Yes, every country has a ratio of doctors per population, how many nurses based on population, number of beds etc. If we are not meeting those requirements then it gives decision makers the real constraints we face in delivering health care to the population.
Dr. Kennedy: If we bound to use WHO, then the guidelines doctor patient and nurse patient ratio plus difference between acute care etc. One to 990 I saw in our infrastructure plan... I saw Chuuk and I using 2000 FSM population Chuuk has 1 to 3000 population, one nurse to 800 something. Yap probably has a very good ratio. From the national government the average might look good, but Chuuk is facing very difficult.
Jeff: Kosrae has lowest rate, the range is big.
Matchigo: When developing a health plan for ratios to bear in mind those standards are set within healthy population. Our population is not healthy. We might need to put less people under one doctor or nurse.
Eliuel: Two points: what is your consideration on sanitation and environmental health. And there is a sector, but environmental health and sanitation is part of public health and not a part of EPA or other agencies. Second if you recall Andon recommending increasing financial technical people to improve accountability under
this new compact agreement, what is the possibility of having a special position for accountant and can reconcile with finance to make sure we are in line with what need to be followed and what need to be reported. Our AO's need assistance. Funds are from so many sources, foreign, WHO, compact, and grants etc, and we must be accountable to all of these. The way it is set up this is very difficult. We are scattered and separated across the states and difficult to get information shared.
Jeff: The same situation that national faces, so do the states.
Wisener: We have one for Pohnpei state.
Mark: We hired one last week.
JP: Sanitation. On one island 100% of the students had worms, high loads. There are kids still using the mangrove, every day. We need basic sanitation, at the minimum a pit latrine. We still see cholera.
Mark: The same with water systems.
JP: That same things that were done in the 1800s we can do here in the 21st century. Basic sanitation, water. We focus on environment as saving trees, saving coral, but I want to focus on health.
Eliuel: Yes, in Pohnpei environment is under EPA. But EPA does not get involved in how to prevent disease.
Bob: Maybe in 3.6 we need to move health... EPA is bogged down in earth moving permits...
Jeff: At yet they are responsible for sanitation.
Bob: One reason kids go to the mangrove is that the bathrooms in their schools do not work.
JP: A major problem is sanitation.
Mark: So part of it is jurisdiction. And part is infrastructure.
Wisener: Can we do something about the environment? Can we make a policy recommendation to move sanitation from EPA to health with those justifications?
Amato: Statistic from census: 27% do not have toilet. 87% in Chuuk do not have toilets. Infectious and parasitic disease control. Tied to economic link. 6% joined sewer system in Chuuk.
Dana: justification is that PHC is already out there on OI, or should be, There is a synergy in moving sanitation to health.
Amato: Health information which include development of health statistics. How to align health information with strategies. We found it difficult to do something. To get statistics office working with health department. The priority has to be shared and to be there. You see 3.6, it is important. We should sanitation as area to work with, all those outfits. 3.8 I separate on 3.8. I hope we can see new activities. 3Viii that is. I tried to specify some outputs.
Jeff: These are proposals that we are working on, we may have to change some of them in five years. We should consider these things.
Mark: They are thought out and data is necessary. I move to adopt.
Jeff: Motioned and seconded.
Bob: Is not this 5.2, part of the health information systems? Would this be part of it.
JP: That is a whole system: accounting, ordering, etc.
Jeff: OK?
Wisener: At the state level we will develop specifics.
Jeff: I think we reach a point near the end.
Arthy: Where do we fit in services for elderly?
Wisener: Although not specifically mentioned, I think we mention the health of the nation and everyone in it.
JP: How many are over 55 in the FSM?
Bob: 357.
JP: 7000. We do not live that long.
Dana: Elderly defined younger here. Someone a year younger than me said they were too old to run.
Jeff: People squeeze in elderly.
Marcus: 6000 above 60 years old. And 60 is the lower boundary for elderly in the FSM.
Jeff: We may be coming late in terms of reporting. Three sectors have volunteered into the first three slots. We might come later so we might have a chance to review these.
Mark: We should add something about infrastructure to really get a handle on that and health services cannot put that infrastructure into place. We cannot be responsible for that, we will require other input from other sectors.
Bob: We are asking other sectors to bring it up to the level it should be at. If they were doing their job we wouldn't be having these problems.
Amato: I think between us, national and state, one of the problems is that sometimes we are agreed on buildings. Is there anywhere we can agree on what to report to the national government and have everyone sign an MOU to agree to submit that. We are social service people, how can we work together.
Bob: I thought we had about six years ago. When we sign the MOU and then the director changes the MOU gets lost.
Eliuel: Once we are done this relates to compact II, all of us follow same procedure and one report will be submitted from national government. It is the priority areas that vary from state to state. That is something all of us should keep in mind.
Amato: For example: MDG requirements, a treaty we have to comply with. Sometimes when we ask, we get, "What do you need that for?"
Jeff: I understand. We agree to many treaties, and then implementation time comes and we do not comply. We have to be diplomatic. When we ask other sectors for support bear in mind health and education are already getting the lion's share of the money.
Mark: There are areas we have to ask for help. Water systems, electricity, etc. We cannot do it, but need it done for improving health.
With this the session turned to plans for tomorrow's presentation at the plenary. By 1700 the group had dispersed.
~~~
All errors are solely those of the editor of this document. Questions about this document, or corrections should be sent to dleeling@comfsm.fm